scrotal lump post pic

Scrotal Lump – OSCE Case

If you'd like to support us, check out our awesome products:

Introduction

You are a junior doctor working in urology. A 27 year old man has been referred to your clinic with a scrotal lump. Work through the case to reach a diagnosis.

UK Medical Licensing Assessment (UKMLA)

This clinical case maps to the following UKMLA presentations:

  • Scrotal/testicular pain and/or lump/swelling

History

Presenting complaint

“I’ve felt this lump down below, it’s on the left side in the scrotum'”

History of presenting complaint

Onset: When did he first notice the swelling?

Size: Has the swelling grown?

Pain: Is it painful or painless? It may be useful to use the SOCRATES framework for inquiring about pain.

  • Site
  • Onset of pain (e.g. sudden, gradual)
  • Character (e.g. sharp, dull)
  • Radiation
  • Associated symptoms with pain (e.g. nausea, vomiting)
  • Timing (e.g. is the pain related to anything?)
  • Exacerbating & relieving factors (i.e. things that make the pain worse/better)
  • Severity (e.g. scale of 1-10)

Was there any preceding trauma?

Associated symptoms: Infective symptoms such as fever or dysuria, systemic symptoms such as weight loss or night sweats.

Answer

β€œI noticed it in the shower a few weeks ago – I didn’t think much at first because it doesn’t hurt, but now I think it’s getting bigger. I feel fine though.”

Other areas of the history

Sexual history

See the Geeky Medics guide to taking a sexual history.

Past medical history

  • Other medical diagnoses (e.g. patients with Klinefelter’s and Kallman’s syndrome have a greater risk of testicular cancer)
  • Previous hospitalisations
  • Previous abdominal, pelvic or perineal surgeries
  • Specifically, ask about a history of childhood cryptorchidism (higher risk of testicular cancer)

Medications/allergies

Family history

Specifically, ask about a family history of testicular cancer.

Social history

  • Smoking history
  • Alcohol history
  • Illicit drug use
  • Occupation
  • Relationships/family
  • Fertility status

Answer

β€œI’ve never had to come to the hospital before. I’m really worried because my Dad had one of his testicles removed, he had cancer when he was about my age.Β  My wife and I want a baby- I don’t want to lose mine.”


Clinical examination

General examination of the patient: Do they look well? Have they got signs of infection? Do they look cachexic? Are they in pain?

This patient requires a comprehensiveΒ testicular and scrotal examination to assess:

  • Site of swelling
  • Size of swelling
  • Shape of swelling
  • Colour: Are there overlying skin changes?
  • Consistency: Is the lump firm or fluctuant?
  • Tenderness: Is it painful to examine?
  • Temperature: Is it hot to touch? (may indicate infection)
  • Scars: signs of previous surgery.
  • Cremasteric reflex/ Prehn’s sign

Chest and abdominal Examination: Specifically examine for palpable lymph nodes or signs of lung metastasis (both signs of testicular cancer).

Findings

  • Testicular examination reveals a painless, firm, irregular, intratesticular swelling on the left hemiscrotum
  • There are no overlying skin changes
  • Transillumination is negative
  • Abdominal and respiratory examination are unremarkable

Investigations

  • Urinalysis: may show white cells (infection) or red cells (haematuria)
  • Bloods: FBC, U&E, CRP (can consider tumour markers if concerned – bHCG, LDH, AFP)
  • Ultrasound scan of the scrotum: this is the recommended first-line investigation for any scrotal lumps
  • Chest X-ray/CT: if concerned about malignancy and metastasis

Findings

  • Urinalysis is normal
  • FBC, U&E and CRP are normal

Diagnosis

Benign:

Malignant:

  • Germ cell tumour
  • Stromal tumour
  • Lymphoma
  • Secondary malignancy

The most likely diagnosis is a testicular tumour.

See Table 1 for help with distinguishing clinical features of scrotal masses.

Table 1. Distinguishing scrotal masses by key clinical and investigative features

  Age Pain Urine dip Separate from testis Transillumination Consistency Other features
Epididymo-orchitis Adult Yes +ve No No Tense Fever, erythema, hot to touch

Hydrocele

 

Any No -ve Yes Yes Fluctuant May be very large

Varicocele

 

Adult No -ve No No β€œbag of worms”  
Epididymal cyst Any No -ve Yes Yes Fluctuant  

Torsion

 

Teen Yes -ve No No   Vomiting, high riding testis

Cancer

 

20-40

 

No -ve No No Firm, irregular Weight loss, lymph nodes

Hernia

 

Any Either -ve Can’t get above No Depends if incarcerated or not May be reducible

Management

This patient has features suggestive of testicular cancer. The patient will require imaging, a multidisciplinary team (MDT) discussion, subsequent orchidectomy (via groin approach) and counselling about sperm banking.

Management of scrotal lumps depends on the suspected underlying diagnosis.Β 

In most cases, scrotal ultrasound is a useful investigation

  • However, this shouldΒ not be performed in cases of suspected testicular torsion asΒ immediate scrotal exploration is indicated

Infective causes may be managed with antibiotics or incision and drainage if an abscess is present.

Benign cysts and hydroceles may be left alone unless they are causing discomfort.

An inguinoscrotal hernia should be surgically repaired to prevent complications.


Reviewer

Mr Sachin Malde

Consultant Urologist


Editor

Hannah Thomas


References

  1. European Association of Urology. Oncology Guidelines. Published in 2020. [LINK]
  2. British Association of Urological Surgeons.Β Testicular Lumps.Β  Published in 2019. [LINK]

Β 

Print Friendly, PDF & Email